Monday, June 5, 2023
This article targets primary care physicians, rheumatologists, dermatologists, and other specialists who care for patients with psoriasis.
The goal of this review is to update physicians on new treatment modalities for psoriatic arthritis.
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Purpose of Review: This paper will review the data published in 2004 on the treatment of psoriatic arthritis, which arthritis affects 6 to 39%
of all patients with psoriasis.
Recent Findings: New data from placebo-controlled trials of anti-tumor necrosis factor agents, etanercept, infliximab, and adalimumab continue
to show sustained effectiveness of these therapies in their ability to control the symptoms and signs of both arthritis and
psoriasis, improve quality of life and function, and inhibit disease progression as measured by radiologic changes. Medications
that inhibit T cells have been approved for the treatment of psoriasis and have been studied in psoriatic arthritis. The effectiveness
of one of these agents, efalizumab, did not achieve statistical significance in the treatment of psoriatic arthritis. The
results of a trial with a second agent, alefacept are pending public review.
Summary: There has been a persistent increased focus on the diagnosis and treatment of psoriatic arthritis as newer and more effective
drugs than traditional disease-modifying agents have become available.
Psoriatic arthritis (PsA) is a chronic inflammatory arthritis, which occurs in 6 to 39% of patients with psoriasis, depending on the population studies and the method of diagnosis ascertainment.[1-4] Psoriasis occurs in approximately 2% of the population of North America and Europe.[5] A higher prevalence is documented when the disease is assessed in psoriasis-specific populations, especially those with more severe disease, whereas lower prevalence is documented in large population surveys, which include patients with psoriasis of low severity.[1-4] A difficulty with accurate determination of prevalence from large population cohorts is that the diagnosis may be overestimated, for example, if a psoriasis patient with concomitant osteoarthritis or rheumatoid arthritis is mistakenly categorized as having PsA. Conversely, the disease may be underestimated if a psoriasis patient with PsA receives instead a diagnosis of osteoarthritis - a disease better known to primary care physicians.
Psoriatic arthritis is an immunologic inflammatory disease, akin to but distinct from rheumatoid arthritis (RA) and other inflammatory arthritides.[6] Understanding of the immunologic pathophysiology of PsA, which has important similarities and differences with RA, and between skin lesions of psoriasis and joint inflammation of PsA, has led us to targeted therapy. A review of this area is beyond the scope of this article and has been well reviewed in this journal and elsewhere.[7*,8,9*-11*,12] A fellow paper in this issue is related to PsA pathogenesis and clinical. Increased understanding of the pathophysiology of PsA demonstrates the central role of inflammatory cytokines such as tumor necrosis factor (TNF)α and activated T cells, which are targets of current targeted therapies. Several other cellular, cytokine, and chemokine targets have been identified, and there are numerous drug development programs in RA, PsA, and psoriasis aiming at these additional targets, which will affect future options for PsA therapeutics.
Several important therapeutic studies in PsA described in a review article in this journal last year, while in abstract form, have been published in 2004, and will be further detailed here.[13] Additionally, several drug development programs in PsA as well as psoriasis have matured, thus providing further data to review. As a result of findings from these studies, rheumatologists, now quite familiar with the use of biologics for the treatment of rheumatoid arthritis (RA), are actively using these agents in PsA patients with progressive disease who have not adequately responded to nonsteroidal anti-inflammatory drug (NSAID) or traditional disease-modifying antirheumatic drug (DMARD) therapy alone. In parallel, the approval of biologics for the treatment of moderate to severe psoriasis has resulted in rapid uptake of these agents by many dermatologists. It is likely that this dual discipline use will increase the effective treatment of previously undiagnosed and un- or undertreated PsA patients who are primarily treated in dermatology and primary care offices. Whether this trend will affect the natural history of PsA or even prevent its emergence, which usually first manifests years after psoriasis begins, is unknown. Overall awareness about PsA has risen through the educational efforts of patient service organizations globally, such as the National Psoriasis Foundation in the United States and country-specific organizations in Europe and other parts of the world. These are supported both by international consortia of psoriasis and PsA researchers such as the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) as well as the biopharmaceutical industry. A multiarticle supplement of the Annals of the Rheumatic Diseases, with state-of-the-art reviews on psoriasis and PsA by GRAPPA members, will be published in March 2005.
